Apply to Become A Patient

Patient Requirements:

    1. Live anywhere in Mecklenburg or Union County, NC
    2. Be 18-64 years old
    3. Not have Medicaid (Family Planning Medicaid does not disqualify), Medicare, VA, or private insurance
    4. Be at or below 250% of the current year’s Federal Poverty Guidelines (click here for the 2024 chart. Locate household/family size, max income for that row can be found in the 250% column)
    5. Once you submit your application through the form below, a member of the Applications Team will contact you within 3-5 business days
    6. Please call (704) 841-8882, option 1, and ask for new patient information if you have any questions about the application process

What You Will Need To Apply:

If there is a document that you would like to provide us as a part of the application that is not listed below, please give us a call to confirm the document can be accepted. At least one document must be submitted from each of the three categories below (three documents total):

  • Proof of Identity: A government, work, school, or organization-issued photo ID is required for the proof of identity; it cannot be expired. Please DO NOT upload birth certificates.
    • Driver’s License
    • Photo ID Card
    • Passport
    • Consulate Card
    • Student ID
  • Proof of Where You Live: The proof of residency must have a date visible in the upload that is within the last 30 days.
    • Utility Bill
    • Hospital Bill
    • Advertisements
    • Postmarked Letter
  • Proof of Income: If you have multiple forms of income in your household, provide documentation for each income source. Income documentation must be uploaded for both the applicant and any spouse/partner living in the same household. *Please provide as many as apply.
    • Last 30 days of paystubs
    • If you paid cash, a letter from employer stating how many hours worked per week and rate of pay per hour; the letter must be signed and dated
    • If self-employed, copy of 3 most recent, consecutive bank statements
    • Copy of award letter showing monthly benefit for any additional income such as Unemployment, Disability, Social Security, etc.
    • If neither the applicant nor spouse/significant other has income, please provide a completed letter of support stating how the applicant is supported financially. The letter must be dated and signed by the person providing support, must state the type of support they are providing, their address and contact number, and their relationship to the applicant.
    • Copy of previous year’s Tax Return